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Information request medical record - Authority

Requesting information
Authorization minors
Process and receipt
Contact
Request form

With this form, an agency or external advocate submits an information request regarding medical records of a patient at UMC Utrecht or the WKZ.

Directly to request form

Are you a healthcare provider and requesting information for the purpose of (follow-up) treatment? Do this directly at the outpatient clinic.

Requesting information uitklapper, klik om te openen

You fill in the form below;
you enter your e-mail address is for receipt of medical information. Required only for receipt of radiological images;
you attach an authorization to this form with the following requirements:

patient's name and date of birth;
patient's signature with date of signature;
The authorization must show specifically and unambiguously that the patient gives us, the UMC Utrecht /the healthcare providers of the UMC Utrecht permission to breach medical confidentiality and share medical data with third parties.

You can add your letter(s) as an attachment if you wish.

Authorization minors uitklapper, klik om te openen

Child younger than 12: an authoritative parent signs the authorization.

Child between the ages of 12 and 16: a custodial parent and the child both sign the authorization.

Child 16 years of age or older: sign the authorization yourself.

Process and receipt uitklapper, klik om te openen

We aim to provide you with feedback within four (4) weeks. Due to administrative pressures - and pressure on care in general - feedback may take longer.

Contact uitklapper, klik om te openen

If you would like to inquire about the status of your already submitted request or have a question about the request form, please contact Team Delivery File at teamuitleveringdossier@umcutrecht.nl or call 088 755 88 01

Due to the privacy of our patients, we do not provide medical information over the phone. We rely on your understanding.

Request form uitklapper, klik om te openen

1. Requesting agency data.

Name authority

Name and position of authorized representative

Street and house number or PO Box number (no reply number)

Postal code and city

E-mail address for receipt of medical data

Phone number contact person

Your reference

Invoice data

Cost center and/or invoice reference

Email address for invoice

Billing address (if different than mailing address provided)

SEND MEDICAL INFORMATION BY (make a choice). Secure email By certified mail

2. Patient data

Last name

First name

Female/ Male/ Other

Date of birth

Address and house number

Postal code and city

Phone number

Patient number

Clinician

3. Information Request

Specialty(s)

Period (e.g., 01-01-2021 to 31-01-2021)

What information are you requesting

Reason for request

Attach authorization form here. Voeg een bijlage toe max. 5MB

Add additional information here. Voeg een bijlage toe max. 5MB

If desired, you can add an additional attachment here. Voeg een bijlage toe max. 5MB

Thank you for your review!

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